import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: With spiral cord - displaced CENTRAL (medial), SUPERFICIAL (toward skin), and PROXIMAL (higher than normal). May lie directly beneath skin. **Protection**: Early identification in normal tissue proximally. Gentle spreading technique. Trace continuously throughout dissection. NEVER assume normal position. **Location**: Run with digital nerves in neurovascular bundle. Displaced by spiral cord in similar pattern to nerves. Usually palmar to nerve. **Protection**: Identify with nerves. Use bipolar cautery only. Preserve both arteries if possible - digit usually survives with single artery. **Location**: Proximal palm at level of extended thumb. Approximately 3-4cm distal to distal wrist crease. Superficial to flexor tendons. **Protection**: Identify during proximal dissection. Stay on fascia. Use spreading technique. Avoid blind clamping or cutting. **Location**: Deep to diseased fascia within flexor tendon sheath. FDS superficial to FDP. Adherent to cord via Grayson's ligament connections. **Protection**: Identify during deep dissection. Preserve tendon sheath integrity. Use gentle spreading parallel to tendon. Avoid tendon laceration. **Location**: Overlying diseased fascia. Often adherent especially with Garrod's pads. Thin and at risk for necrosis. **Protection**: Raise FULL-THICKNESS flaps including dermis. Avoid excessive undermining. Preserve subdermal plexus. Z-plasties for length if needed. ## Surgical Indications **Absolute Indications**: - Positive table top test - inability to place palm flat on surface - MP joint contracture greater than 30 degrees - ANY PIP joint contracture (even 15-20 degrees warrants consideration) - Functional impairment - difficulty with grip, activities of daily living **Relative Indications**: - Rapidly progressive disease despite MP contracture less than 30 degrees - Patient request in younger patients with progressive disease - Concurrent pathology (Garrod's pads, web space contracture) **Contraindications**: - Medical comorbidities precluding anesthesia - Unrealistic patient expectations (especially for severe PIP contracture) - Inability to comply with postoperative therapy and splinting - Active infection in operative field - Severe vascular disease compromising healing ## Preoperative Assessment **Clinical Examination**: - **Table top test**: Place hand flat on table - inability = positive test - **Tubiana staging**: Measure total flexion deformity at MP + PIP for each ray - Stage I: Less than 45 degrees total - Stage II: 45-90 degrees - Stage III: 90-135 degrees - Stage IV: Greater than 135 degrees - **Finger involvement**: Ring finger most common (40%), then small (30%), middle (20%), index (10%) - **Skin quality**: Assess for adherent skin, puckering, Garrod's pads over PIP joints - **Palpate cords**: Identify pretendinous, central, spiral, lateral cords - **Vascular assessment**: Allen test, digital perfusion, capillary refill **Dupuytren's Diathesis** (Poor Prognosis Factors): - Age less than 50 years at onset - Bilateral disease - Ectopic disease (Ledderhose - plantar, Peyronie's - penile) - Family history (autosomal dominant with variable penetrance) - Rapid progression - Garrod's knuckle pads over PIP joints **Imaging**: - NOT routinely required - Plain radiographs if concurrent arthritis suspected - MRI NOT indicated - Ultrasound for research purposes only ## Surgical Planning **Incision Selection**: 1. **Bruner zigzag**: Gold standard for digital incisions - apices at flexion creases, 60 degree angles 2. **Z-plasties**: Add 75% length where skin tight - plan 60 degree angles 3. **Transverse palmar**: For McCash open palm technique 4. **Combination**: Transverse palm with Bruner digits most common **Anesthesia Options**: - Axillary block (preferred for hand surgery) - Bier's block (IVRA) - acceptable alternative - General anesthesia if patient preference or block contraindicated - Wide-awake local anesthesia no tourniquet (WALANT) - emerging technique **Patient Counseling**: - MP contracture: Expect near-complete correction - PIP contracture: May have 20-30 degrees residual - improves with therapy - Recurrence: 30-50% at 5 years for stage III-IV disease - Nerve injury risk: 2-5% (higher with spiral cord) - Recovery: 8-12 weeks to full function - Lifelong night splinting may be recommended ## Palmar Fascia Anatomy **Normal Anatomy**: - **Palmar aponeurosis**: Central triangular structure from palmaris longus - **Longitudinal fibers**: Eight pretendinous bands to digits - **Transverse fibers**: Superficial transverse ligament, natatory ligament - **Sagittal bands**: Vertical septa connecting longitudinal fibers to skin - **Spiral bands**: Connect palmar fascia to lateral digital sheet and Grayson's ligament **Disease Anatomy - Four Cord Types**: 1. **Pretendinous Cord** (Most Common): - Origin: Central aponeurosis - Course: Overlies flexor tendon - Insertion: Flexor tendon sheath - Effect: MP flexion contracture - Nerve position: NORMAL - safe dissection 2. **Spiral Cord** (Most Dangerous): - Origin: Pretendinous cord, spiral band, lateral digital sheet, Grayson's ligament - Course: Spirals around neurovascular bundle from palmar to radial side - Effect: PIP flexion contracture - Nerve displacement: **THREE directions**: - **CENTRAL** (medial) - toward midline - **SUPERFICIAL** - closer to skin, may be subcutaneous - **PROXIMAL** - higher than expected, may be in palm - Maximum nerve injury risk 3. **Central Cord**: - Origin: Central aponeurosis in midline palm - Course: Midline palm to middle finger - Effect: Palmar contracture - Nerve position: Usually not involved 4. **Lateral Cord**: - Origin: Lateral aponeurosis - Course: Radial side of digit - Effect: Radial digital contracture - Nerve position: Usually protected **Ligamentous Anatomy**: - **Cleland's ligament**: Dorsal to neurovascular bundle - protects nerve - **Grayson's ligament**: Palmar to neurovascular bundle - involved in spiral cord - **Lateral digital sheet**: Connects to spiral band, forms spiral cord - **Natatory ligament**: Commissural ligament in web space ## Neurovascular Anatomy **Digital Nerves**: - Common digital nerves divide at web space - Proper digital nerves run palmar to axis of rotation - Course with digital arteries in neurovascular bundle - **Spiral cord displacement**: Central, superficial, proximal **Digital Arteries**: - Common digital arteries from superficial palmar arch - Divide to proper digital arteries at web space - Usually run palmar to nerve - Two arteries per digit - can survive with one if other injured **Superficial Palmar Arch**: - Formed by ulnar artery (dominant) and superficial palmar branch of radial artery - Located 3-4cm distal to distal wrist crease - Level of extended thumb - Gives off common digital arteries ## Positioning and Setup **Patient Position**: - Supine on operating table - Affected upper extremity on radiolucent hand table at 90 degrees abduction - Ensure adequate padding of bony prominences - Access to entire arm from shoulder to fingertips **Anesthesia**: - Regional block (axillary or Bier's) preferred - General anesthesia acceptable - WALANT (wide-awake local anesthesia no tourniquet) - emerging - Sedation as needed for patient comfort **Tourniquet Application**: - Sterile or non-sterile tourniquet on upper arm - Padding beneath tourniquet - Pressure: 250mmHg (or 100mmHg above systolic) - Exsanguination: Elevation only (avoid Esmarch if vascular compromise) - Maximum tourniquet time: 2 hours (typically adequate) **Sterile Preparation**: - Prep entire upper extremity from shoulder to fingertips - Include hand and all digits in prep - Chlorhexidine or iodine-based solution - Drape to expose hand and forearm ## Surgical Steps ### Step 1: Incision Planning and Execution **Bruner Zigzag Incisions**: - Mark incision with surgical pen before inflation - Apices at flexion creases (palmar digital crease, PIP crease, DIP crease) - 60 degree angles from longitudinal axis - Avoid apices in web space (risk of contracture) - Extend proximally into palm as needed - Full-thickness flaps including dermis to subdermal fat junction **Z-Plasty Planning**: - Plan 60 degree angles for 75% length increase - Central limb along line of contracture - Two lateral limbs at 60 degrees - All limbs equal length - Mark before incision **McCash Open Palm**: - Transverse incision in distal palm - Perpendicular to longitudinal axis - Length: 3-4cm typically - Plan to leave OPEN - counsel patient preoperatively **Incision Execution**: - Use 15 blade for sharp incision through skin - Raise full-thickness flaps immediately - Include dermis in flap - thin flaps necrose - Use skin hooks for retraction (avoid crushing forceps) - Elevate flaps to expose diseased fascia **Technical Tip**: "I mark all incisions with the tourniquet deflated so anatomy is normal. Bruner zigzag with apices at flexion creases prevents linear scar contracture. Critical point: FULL-THICKNESS flaps including dermis - thin flaps are the most common cause of skin necrosis." - Thin skin flaps (less than 2mm) = necrosis (most common wound complication) - Longitudinal incisions crossing flexion creases = scar contracture - Incision apices in web space = web space contracture - Crushing skin with forceps = tissue damage ### Step 2: Identify Normal Anatomy Proximally **Start in Normal Tissue**: - Begin dissection in palm proximal to diseased cord - Identify normal palmar aponeurosis: white, glistening, longitudinal fibers - Normal fascia is thin (1-2mm), mobile, soft - Diseased fascia is thick (5-10mm), adherent, firm, yellow **Establish Anatomic Planes**: - Plane between subcutaneous fat and fascia - Plane between fascia and underlying flexor tendons - Use spreading technique with small scissors or forceps - Gentle traction on fascia to define deep plane **Identify Normal Structures**: - Central aponeurosis in midline - Pretendinous bands (eight longitudinal bands to digits) - Sagittal bands (vertical connections to skin) - Transverse fibers superficially - This provides roadmap before entering diseased tissue **Technical Tip**: "I always start in normal tissue proximally where anatomy is predictable. This establishes my reference planes. Normal palmar fascia is white and glistening like plastic wrap. Diseased tissue is thick and yellow like leather. Starting in disease leads to disorientation." - Starting in diseased tissue = anatomic disorientation - Inadequate proximal exposure = missing extent of disease - Damage to normal structures (nerve, vessel) during proximal dissection - Insufficient identification of normal landmarks ### Step 3: Identify and Classify Disease Cords **Follow Fascia to Disease**: - Trace normal fascia distally to point of thickening - Diseased cord is firm, thick, yellow, adherent - May be adherent to overlying skin - Separate skin from cord if adherent using spreading technique **Classify Cord Type** (Critical for Nerve Safety): 1. **Pretendinous Cord**: - Most common - Overlies flexor tendon in midline of ray - Nerve position NORMAL (radial and ulnar sides) - Relatively safe dissection 2. **Spiral Cord** (DANGER): - Look for origin from pretendinous cord - Spirals from palmar to radial side around neurovascular bundle - Nerve displaced: CENTRAL, SUPERFICIAL, PROXIMAL - Maximum nerve injury risk - Must identify nerve EARLY 3. **Central Cord**: - Midline palm - Usually not involving neurovascular structures 4. **Lateral Cord**: - Radial side of ray - Less common - Usually safe dissection **Key Decision Point**: - If SPIRAL CORD identified → STOP and identify nerve BEFORE further dissection - If PRETENDINOUS CORD → can proceed with cord dissection and nerve identification concurrently - Use loupe magnification (2.5x or 3.5x) for all cord dissection **Technical Tip**: "Identifying cord type is the critical decision point. SPIRAL CORD means the nerve is in danger - I must find the nerve BEFORE dissecting the cord. With spiral cord, the nerve can be directly beneath the skin in abnormal position. Pretendinous cord is safer as nerve position is normal." - Not recognizing spiral cord = proceeding with dissection = nerve transection - Assuming normal nerve position with spiral cord - Inadequate classification before proceeding - Blind dissection without cord type identification ### Step 4: Identify Neurovascular Bundles EARLY **Critical Technique for Spiral Cord**: - Identify nerve BEFORE aggressive cord dissection - Start proximally in palm where anatomy more normal - Use GENTLE SPREADING technique with fine scissors - Look for longitudinal yellow/white structure - Nerve has longitudinal striations (vs smooth vessel) - Trace nerve proximally AND distally **Nerve Identification Techniques**: - Look for mesoneurium (thin connective tissue envelope) - Gentle palpation - nerve feels like firm string - Test with gentle traction - nerve moves longitudinally - Artery pulsates (may need tourniquet deflation briefly) - Use vessel loops to protect identified structures **Nerve Position with Spiral Cord**: - May be CENTRAL (medial) - toward midline of finger - May be SUPERFICIAL - directly beneath skin, subcutaneous - May be PROXIMAL - in palm rather than digit - DO NOT assume normal radial/ulnar position **Protection Strategy**: - Use vessel loops around identified nerves - Gentle retraction only - Maintain visualization throughout dissection - Never lose sight of nerve - Assistant retracts nerve while surgeon dissects cord **Technical Tip**: "With spiral cord, I identify the nerve BEFORE cord excision. I start proximally and trace the nerve distally. The nerve may be in very abnormal position - central, superficial, proximal. I use vessel loops and gentle retraction. Never proceed with blind dissection if you cannot see the nerve." - Nerve transection (2-5% incidence, higher with spiral cord) - Digital artery injury (1-2%, may compromise viability) - Delayed nerve identification = increased risk - Excessive traction on nerve = neuropraxia - Blind dissection = disaster ### Step 5: Limited Fasciectomy - Cord Excision **Modern Technique** (Limited, Not Radical): - Excise ONLY diseased cord - Preserve ALL normal fascia - Preserve ALL neurovascular structures - Preserve flexor tendon sheath integrity **Palmar Cord Dissection**: - Dissect cord from overlying skin using spreading technique - Dissect cord from underlying flexor tendons - Identify and protect neurovascular bundles - Excise cord from proximal extent to digital extension **Digital Cord Dissection**: - Continue into digit along involved ray - Spiral cord inserts on lateral digital sheet and Grayson's ligament - Cord may wrap around neurovascular bundle - Dissect cord from nerve using spreading parallel to nerve - Preserve Cleland's ligament (dorsal, protective) - Excise Grayson's ligament as part of cord (palmar, involved) **Dissection Technique**: - Use small scissors or fine forceps - Spread parallel to nerve direction - Gentle traction on cord away from nerve - Direct visualization at all times - Loupe magnification essential - Bipolar cautery for small vessels only **Extent of Resection**: - Proximal extent: Normal fascia in palm - Distal extent: DIP joint level if involved - Complete excision of all diseased tissue - Tag specimens if multiple rays for pathology orientation **Technical Tip**: "LIMITED fasciectomy is modern gold standard - excise only diseased cord. RADICAL fasciectomy (removing all fascia including normal) has higher morbidity without proven benefit for recurrence. Evidence shows similar recurrence rates with much lower complication rate for limited approach." - Incomplete excision = higher recurrence (main cause) - Excessive dissection = nerve/vessel injury - Flexor sheath violation = adhesions and triggering - Aggressive dissection = skin flap devascularization ### Step 6: Address Joint Contracture **Passive Correction Assessment**: - After cord excision, assess passive ROM - MP contractures usually correct fully (excellent outcomes) - PIP contractures often persist (capsular contracture) - Measure residual contracture with goniometer **MP Joint** (Usually Full Correction): - Cord excision usually sufficient - Rarely need capsular release - Gentle manipulation acceptable **PIP Joint** (Often Persistent Contracture): - **Checkrein ligament release**: - Accessory collateral ligaments on volar aspect - Insert on volar plate - Release with curved scissors - Bilateral release (radial and ulnar) - **Volar plate release**: - If checkrein release insufficient - Proximal volar plate release from A2 pulley - Preserve proper collateral ligaments - **CRITICAL**: Do NOT force full extension - Risk of flare reaction - Acceptable to leave 20-30 degrees residual - Will improve with therapy **Flare Reaction** (AVOID): - Severe inflammation, pain, stiffness - Caused by forced manipulation - May require stellate ganglion block, therapy - Prevention: Accept residual contracture **Technical Tip**: "PIP contractures are the challenge. After cord excision, I release checkrein ligaments volar to axis of rotation. CRITICAL EXAM POINT: I NEVER force full correction. Forced manipulation causes flare reaction - severe inflammation and stiffness worse than original contracture. Better to accept 20-30 degrees and gain correction gradually." - Forced manipulation = flare reaction (CRPS-like picture) - Collateral ligament injury = joint instability - Inadequate release = persistent contracture - PIP joint cartilage damage from forced extension ### Step 7: Manage Associated Pathology **Garrod's Knuckle Pads**: - Fibrotic thickening over PIP dorsum - Part of Dupuytren's diathesis - If adherent to cord → excise with fasciectomy - If independent → may leave alone - Defect may require skin graft **Web Space Contracture**: - Release natatory ligament if contracted - May require Z-plasty for skin lengthening - Preserve neurovascular structures in web - Avoid web space narrowing **Thumb Involvement**: - Less common but important - Release thenar fascia if involved - Preserve recurrent motor branch of median nerve (thenar) - May affect thumb IP or MP joint **First Web Space**: - Release if contracted - Critical for grip function - Z-plasty commonly needed - Skin graft if severe **Technical Tip**: "Garrod's pads are associated with diathesis - poor prognostic factor. When adherent to cord, they need excision which may require skin graft. Web space contracture severely limits grip - I release natatory ligament and use Z-plasty for skin length." - Skin bridge necrosis between adjacent fingers - Web space narrowing from inadequate skin - Recurrent motor branch injury (thumb) - Incomplete web release = persistent functional impairment ### Step 8: Achieve Hemostasis **Tourniquet Release**: - Release tourniquet after dissection complete - Allow 5-10 minutes for vessel bleeding - Irrigate with warm saline **Hemostasis Technique**: - Meticulous bipolar cautery - Avoid excessive cautery near nerves - Address all bleeding points - Aim for completely dry field **Check Digital Perfusion**: - Observe capillary refill in all digits - Check color (pink vs pale/blue) - Check turgor (full vs collapsed) - Rarely may have compromised one digital artery - digit usually survives with one **Drain Consideration**: - Consider small Penrose drain if: - Extensive dissection - Multiple rays - Difficulty with hemostasis - Remove at 24-48 hours **Technical Tip**: "I release tourniquet and achieve meticulous hemostasis. Hematoma is a major cause of infection, flare reaction, and poor outcomes. I use bipolar cautery away from nerves. If I've compromised one digital artery during dissection, the digit usually survives on single artery." - Hematoma (2-5% incidence) = infection risk, flare reaction - Unrecognized vascular compromise = digital necrosis - Excessive cautery near nerve = thermal injury - Inadequate hemostasis before closure = disaster ### Step 9: Skin Closure Strategy **Digital Incisions** (ALWAYS Close): - Use 4-0 or 5-0 nylon interrupted sutures - Simple interrupted technique - Evert skin edges slightly - No tension on closure - Ensure adequate skin length (Z-plasty if needed) - Leave sutures 2 weeks **Palmar Incision** (Two Options): **Option 1: McCash Open Palm** (Preferred by Many): - Leave transverse palmar incision OPEN - Allows drainage, prevents hematoma - Reduces flare reaction - Heals by secondary intention in 4-6 weeks - Well tolerated by patients - Pack with non-adherent dressing **Option 2: Primary Closure**: - Close with interrupted nylon if: - Adequate skin - Z-plasties provide length - No tension - Risk of hematoma higher - Consider drain **Skin Grafting** (Rare): - If large skin defect - Full-thickness skin graft preferred - Donor: groin or hypothenar region - Tie-over bolster dressing - More common with dermofasciectomy **Technical Tip**: "McCash open palm technique: I leave the transverse palmar incision open to heal by secondary intention. This significantly reduces hematoma and flare reaction rates. Patients tolerate it well and healing occurs in 4-6 weeks with excellent outcomes. I ALWAYS close digital wounds to prevent infection." - Tension on digital closure = skin necrosis (most common wound complication) - Closed palmar wound with hematoma = infection, flare - Skin graft in poor bed = failure - Open digital wounds = infection risk ### Step 10: Dressing and Splinting **Dressing**: - Non-adherent dressing over all wounds - Open palm packed with non-adherent gauze - Fluffed gauze between digits - Bulky cotton padding over hand - Soft bandage wrap (Kerlix) - Elevation critical **Dorsal Extension Splint**: - Dorsal thermoplastic splint (not circumferential) - Position: - Wrist 30 degrees extension - MCPs in full extension (0 degrees) - IPs in extension or 10-20 degrees flexion if PIP very stiff - Extend from mid-forearm to fingertips - Include all operated digits - Secure with bandage wrap - Allow wound inspection without splint removal **Postoperative Instructions**: - Strict elevation above heart for 48 hours - Ice to forearm (not directly on hand) - No dependent positioning - Monitor for excessive pain (compartment syndrome rare but possible) - Neurovascular checks **Technical Tip**: "I apply dorsal extension splint to maintain the correction achieved in surgery. This prevents night flexion posturing. Splint is worn continuously for 2 weeks, then night-only for 3-6 months. Elevation in first 48 hours is critical to prevent hematoma and swelling." - Inadequate splinting = loss of correction overnight - Circumferential cast = compartment syndrome risk - Overly tight dressing = vascular compromise - Pressure sores from splint - Dependent positioning = swelling, hematoma ## Radical Fasciectomy (Dermofasciectomy) **Indications** (Limited, Not Routine): - Severe Dupuytren's diathesis (young age, bilateral, rapid progression, family history) - Recurrent disease after prior fasciectomy - Extensively adherent skin requiring excision - Research suggests possible benefit in diathesis patients **Technique**: - Excision of ALL palmar fascia (diseased AND normal) - Excision of overlying diseased skin - Large palmar and digital defect created - Full-thickness skin graft coverage - Donor site: groin (preferred) or hypothenar - Tie-over bolster dressing for 5-7 days **Advantages**: - May reduce recurrence in very high-risk patients - Removes all potentially diseased fascia - Addresses severely adherent skin **Disadvantages**: - Higher morbidity than limited fasciectomy - Donor site morbidity and scar - Skin graft care and fragility - Longer recovery (12-16 weeks vs 8-12 weeks) - Higher complication rate - NO proven benefit for routine cases **Evidence**: - No randomized trials showing superiority for recurrence - Observational data mixed - Modern consensus: Reserve for selected severe cases - NOT recommended as routine approach **Technical Tip**: "For the exam, I would state: Radical fasciectomy or dermofasciectomy involves excision of all palmar fascia and overlying skin with skin graft reconstruction. It has higher morbidity with donor site, graft care, and longer recovery. Evidence does NOT support routine use. I reserve it for severe diathesis or recurrent disease after counseling on increased morbidity." ## Needle Aponeurotomy (Percutaneous) **Technique**: - Percutaneous cord division using hypodermic needle - Multiple punctures weaken cord - Manual manipulation ruptures cord - Office-based procedure under local anesthesia **Advantages**: - Minimal morbidity - Office-based - Rapid recovery - Low complication rate - Can repeat **Disadvantages**: - High recurrence (50-85% at 5 years) - Risk of nerve or tendon injury (2-5%) - Incomplete correction - Better for MP than PIP - Not suitable for spiral cord **Indications**: - Elderly patients with comorbidities - MP contracture only - Patient preference for minimally invasive - Bridging to surgery ## Collagenase Injection (Xiaflex) **Technique**: - Injection of Clostridium histolyticum collagenase into cord - Enzymatic digestion of collagen - Manual manipulation 24 hours later to rupture cord - Office-based procedure **Advantages**: - Non-surgical - Office-based - Rapid recovery - Lower short-term morbidity **Disadvantages**: - Moderate recurrence (47% at 5 years for MP, 66% for PIP) - Expensive - Risk of tendon rupture (flexor, extensor) - Risk of CRPS - Skin tears - Not suitable for spiral cord **Indications**: - Single cord contracture - MP contracture preferred - Patient preference for non-surgical - Medical comorbidities ## Treatment Algorithm **Mild Disease** (MP less than 30 degrees, no PIP): - Observation - Splinting (unproven efficacy) - Monitor for progression **Moderate Disease** (MP greater than 30 degrees, PIP less than 40 degrees, good surgical candidate): - Open limited fasciectomy (gold standard) - Alternative: Collagenase injection if patient preference **Severe Disease** (PIP greater than 40 degrees, multiple rays): - Open limited fasciectomy - Counsel on realistic outcomes for PIP - Night splinting critical postoperatively **Severe Diathesis** (young, bilateral, rapid, family history): - Consider radical fasciectomy - Counsel on higher recurrence risk regardless of technique - Lifelong monitoring **Recurrent Disease**: - Needle aponeurotomy if mild - Repeat limited fasciectomy if moderate - Consider radical fasciectomy if severe/diathesis - Amputation for severe recurrent PIP contracture (rare) ## Postoperative Management Protocol **Immediate Postoperative (Day 0-3)**: - Strict elevation above heart level - Ice to forearm (not directly on hand) - Dorsal extension splint continuously - Pain management (acetaminophen, NSAIDs, opioids short-term) - Neurovascular checks - Monitor for excessive pain (compartment syndrome) **Early Phase (Day 3-14)**: - First dressing change day 3-5 - Remove bulky dressing, inspect wounds - Redress with lighter dressing - Begin active ROM exercises IN SPLINT - Gentle fisting - Digit flexion/extension - Thumb opposition - Continue elevation when not exercising - Splint continuously between exercises - Open palm wounds: daily dressing changes, monitor granulation **Intermediate Phase (Week 2-6)**: - Suture removal at 2 weeks (digital wounds) - Continue ROM exercises OUT of splint during day - Night extension splinting (critical for 3-6 months) - Hand therapy referral - Progressive ROM and light strengthening - Scar massage once wounds healed - Open palm: continue dressing until healed (4-6 weeks) **Late Phase (Week 6 - Month 6)**: - Night extension splinting continues 3-6 months - Progressive strengthening - Full ROM expected by 8-12 weeks - Return to manual labor 8-12 weeks - Return to sports 12 weeks - Lifelong monitoring for recurrence **Hand Therapy** (Critical Component): - Begin therapy at 2 weeks - Focus on: - ROM restoration - Scar management - Edema control - Strengthening - Functional activities - Splint fabrication and monitoring - Frequency: 2-3 times per week for 6-8 weeks ## Complications - Recognition and Management ## Infection Management **Superficial Wound Infection** (1-3%): - Usually Staphylococcus aureus - Increased risk with hematoma, diabetes - Treatment: Oral antibiotics (cephalexin or clindamycin), local wound care - Usually resolves without surgical intervention **Deep Infection** (Less than 1%): - Requires surgical debridement - IV antibiotics - May require skin graft after infection cleared - Rarely progresses to flexor tenosynovitis ## Return to Function Timeline - **Office work**: 2-3 weeks - **Light manual labor**: 6-8 weeks - **Heavy manual labor**: 10-12 weeks - **Contact sports**: 12 weeks - **Maximum medical improvement**: 6 months - **Long-term monitoring**: Lifelong for recurrence ## References 1. Becker GW, Davis TR. The outcome of surgical treatments for primary Dupuytren's disease - a systematic review. J Hand Surg Eur Vol. 2010;35(8):623-626. doi:10.1177/1753193410373845 2. Dias JJ, Singh HP, Ullah A, Bhowal B, Thompson JR. Patterns of recontracture after surgical correction of Dupuytren disease. J Hand Surg Am. 2013;38(10):1987-1993. doi:10.1016/j.jhsa.2013.06.038 3. Grazina R, Teixeira S, Ramos R, Sousa H, Ferreira A, Lemos R. Dupuytren's disease: where do we stand? EFORT Open Rev. 2019;4(2):63-69. doi:10.1302/2058-5241.4.180021 4. Herrera FA, Benhaim P, Suliman A, Roostaeian J, Azari K, Mitchell S. Cost comparison of open fasciectomy versus percutaneous needle aponeurotomy for treatment of Dupuytren contracture. Ann Plast Surg. 2013;70(4):454-456. doi:10.1097/SAP.0b013e31827fb1b0 5. Hurst LC, Badalamente MA, Hentz VR, et al. Injectable collagenase clostridium histolyticum for Dupuytren's contracture. N Engl J Med. 2009;361(10):968-979. doi:10.1056/NEJMoa0810866 6. McFarlane RM. Patterns of the diseased fascia in the fingers in Dupuytren's contracture: displacement of the neurovascular bundle. Plast Reconstr Surg. 1974;54(1):31-44. 7. Peimer CA, Blazar P, Coleman S, et al. Dupuytren contracture recurrence following treatment with collagenase clostridium histolyticum (CORDLESS [Collagenase Option for Reduction of Dupuytren Long-term Evaluation of Safety Study]): 5-year data. J Hand Surg Am. 2015;40(8):1597-1605. doi:10.1016/j.jhsa.2015.04.036 8. Rodrigues JN, Becker GW, Ball C, et al. Surgery for Dupuytren's contracture of the fingers. Cochrane Database Syst Rev. 2015;2015(12):CD010143. doi:10.1002/14651858.CD010143.pub2 9. van Rijssen AL, ter Linden H, Werker PM. Five-year results of a randomized clinical trial on treatment in Dupuytren's disease: percutaneous needle fasciotomy versus limited fasciectomy. Plast Reconstr Surg. 2012;129(2):469-477. doi:10.1097/PRS.0b013e31823aea95 10. Wilbrand S, Ekbom P, Gerdin B, Kalen S. The sex difference in outcome after surgery for Dupuytren's disease is related to recurrence: a retrospective study of 1,919 operated hands. J Hand Surg Eur Vol. 2018;43(9):949-956. doi:10.1177/1753193418787137

Dupuytren's Contracture - Comprehensive Management (Limited vs Radical Fasciectomy)

Dupuytren's Contracture - Comprehensive Management (Limited vs Radical Fasciectomy)